GW1--05512_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !'
1.Well Contractor Information:
•
Robert Teague 14:WATERZONEs .. :.. •: - i L . .
Well Contractor Name FROM TO DESCRIPTION
2857-A 5� ifs 4 Oi ; y r,
ft ft.
NC Well Contractor Certification Number
°15:OUTERCASING(for multikmiedsvetls)ORIANER-(ffap Iteabler .:::.
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft /l` 6116 tu' SDR-21 PVC
-� � � - O' ...1&INNER.CASINGORTUBING.-(geothermalclosed-loop) -.
2.Well Construction Permit#t5 �'+OL FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJ ,County State.Variance,etc.) ft. ft. In•
3.Well Use(check well use):
ft. ft. 1 in.
7:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural OMunicipal/Public ft. ft, in.
QGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft ft. in.
1lndustrial/Commercial OResidential Water Supply(shared) :`18'.GRVUT..
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring EiRecovery ft. ft. 1 Y�''''...7"•' °r—i; r"
Injection Well: V §
ft ft. q '
DAquiferRecharge DGroundwatcrRcmcdiation _ S'E'
19.SAND/GRAVEL.PACK(if applicable) 4 ::G.;/ll1 A•`" •
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT`1THOD
ft. ft. irirJr`nzi4en I)rr
Aquifer Test �Stormwater Drainage „,sry,:,..r,I t.,.
QExperimental Technology Subsidence Control ft. ft. 4.'e`-1,1,1 ...i.
DGeothermal(Closed Loop) OTracer :20::DRILLING;LOG(attaikadditionalsheetsIfneiiSs y)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soiV ck type,gran size,etc.)
g/ g 0Other(explain under#21 Remarks)
O ft. / 6 .� d 1': r 4 * /;G�
4.Date Well(s)Completed; `/V pm Well1D# i a x+—ft J eft. i'LCA ,f/,1/G .6 L4 L
5a.Well Location: ! I / I .• o v s'ft. ��;r, - � j 1.-t. /G�
11 fro)1 e �4O(1!•.sm,.r11 �,' C ft. ) ci J U�li-e.
Facility/Owner Name ci`lity ID#(if applicable) ft ft I'
• S P1
a51 , 6i gidSti !f c i Nan ft. ft. '
Physical ss,City,and Zip ✓ ft. ft.
A
:21.REMARKSi , =•
In UL3e-1�
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ✓� Jo —
6.Is(are)the well(s)01Permanent or DITemporary Signature of Certified Well Con a Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an xplain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiL&rent(example-3 tr 200•and 2@100') construction to the following: !.
10.Static water level below top of casing:40 (ft.)
Division of Water Resources,Information Processing Unit,
If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For injection Wells: in addition to sending the form to the address in 24a
Air Rota above,also submit one copy off this form within 30 days of completion of well
12.Well construction method: Rotary
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPP Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/z Lbs completion of well construction to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016